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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 015601255
Report Date: 02/19/2025
Date Signed: 02/19/2025 02:34:41 PM

Unsubstantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
OAKLAND ASC, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612
This is an official report of an unannounced visit/investigation of a complaint received in our office on
02/13/2025 and conducted by Evaluator Tonica Syess-Gibson
PUBLIC
COMPLAINT CONTROL NUMBER: 15-AS-20250213125422
FACILITY NAME:BROOKDALE NORTH FREMONTFACILITY NUMBER:
015601255
ADMINISTRATOR:HALL, SIMONE SFACILITY TYPE:
740
ADDRESS:38035 MARTHA AVETELEPHONE:
(510) 797-4011
CITY:FREMONTSTATE: CAZIP CODE:
94536
CAPACITY:40CENSUS: 30DATE:
02/19/2025
UNANNOUNCEDTIME BEGAN:
10:20 AM
MET WITH:Simone Hall, Executive DirectorTIME COMPLETED:
03:00 PM
ALLEGATION(S):
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Facility staff did not ensure medications were dispensed as prescribed
INVESTIGATION FINDINGS:
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On 02/19/2025 at 10:20AM, Licensing Program Analysts (LPAs), T. Syess-Gibson and P. Manalo arrived unannounced to conduct a complaint investigation and to deliver complaint findings for the allegation above. LPAs met with Executive Director (ED), Simone Hall and explained the reason for the visit.

Allegation: Facility staff did not ensure medications were dispensed as prescribed

During the investigation, LPAs interviewed ED and staff members. LPA obtained and reviewed documents (ID and emergency information, physician report, hospice care plan, service plan, bowel movement record, resident assessments, and medication administration record (MAR)). Interviews with staff members revealed hospice nurse administered a medication to the wrong resident.

Continue on LIC9099C
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Harpreet Humpal
LICENSING EVALUATOR NAME: Tonica Syess-Gibson
LICENSING EVALUATOR SIGNATURE:

DATE: 02/19/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/19/2025
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 1 of 2
Control Number 15-AS-20250213125422
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
OAKLAND ASC, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612
FACILITY NAME: BROOKDALE NORTH FREMONT
FACILITY NUMBER: 015601255
VISIT DATE: 02/19/2025
NARRATIVE
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Continued from LIC9099



The facility followed protocol by investigating, notified R1's responsible party (RP), CLLD and hospice agencies involved. LPAs was unable to interview R1 during visit due to a dementia diagnosis.

Although the allegation may have happened or are valid, there is not a preponderance of evidence to prove the alleged violation did occur, therefore this allegation is UNSUBSTANTIATED.

No deficiencies cited during visit.

Exit interview conducted. A copy of this report provided.

SUPERVISORS NAME: Harpreet Humpal
LICENSING EVALUATOR NAME: Tonica Syess-Gibson
LICENSING EVALUATOR SIGNATURE:

DATE: 02/19/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/19/2025
LIC9099 (FAS) - (06/04)
Page: 2 of 2